Provider Demographics
NPI:1982644597
Name:GREEN, DANNY LATRELL (OD)
Entity Type:Individual
Prefix:MR
First Name:DANNY
Middle Name:LATRELL
Last Name:GREEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030 WOODLEA RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-2143
Mailing Address - Country:US
Mailing Address - Phone:601-922-9272
Mailing Address - Fax:601-922-8252
Practice Address - Street 1:4253 ROBINSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-6530
Practice Address - Country:US
Practice Address - Phone:601-922-9272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS745152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist